Introduction

Primary small-bowel follicular lymphoma (FL) often presents as multiple white granular elevations involving from the duodenum to the deep small-bowel. Capsule endoscopy (CE) is useful in evaluating the disease surveillance for primary small-bowel FL, but objective evaluation is difficult in some cases.

Aims & Methods

We aimed to evaluate the usefulness of the deep convolutional neural network (CNN) system using CE images for assessing the disease surveillance of primary small-bowel FL. We enrolled 26 consecutive patients with primary small-bowel FL (all with multiple white granular elevations in the small-bowel at the initial CE) diagnosed between January 2011 and January 2021 who underwent CE before and after watch-and-wait or chemotherapy management. The disease surveillance was evaluated by two physicians and the developed CNN system. To construct the CNN system, it was trained with CE still images using deep learning. Evaluation of the disease surveillance by the CNN system was assessed using the percentage of FL-detected images among all CE images, from the duodenum to the terminal ileum.

Results

Eighteen cases (69%) were managed with a watch-and-wait policy, and 8 cases (31%) were treated by chemotherapy. Among the 18 cases managed with a watch-and-wait policy, the physicians evaluated the lesions as almost the same in 14 cases (78%) and as aggravation in 4 cases (22%). The evaluation of lesions by the CNN system showed almost the same in 13 cases (72%), aggravation in 4 cases (22%), and improvement in 1 case (6%). Among the 8 cases treated by chemotherapy, the physicians evaluated the lesions as improvement in 7 cases (88%) and as almost the same in 1 case (12%). The evaluation of lesions by the CNN system showed improvement in 5 cases (63%), almost the same in 2 cases (25%), and aggravation in 1 case (12%). In 23 of 26 cases (88%), both the physicians and the CNN system had similar results in evaluating the disease surveillance. In 3 of 26 cases (12%), there was a discrepancy between the evaluating by the physicians and the CNN system. This discrepancy of evaluation was attributed to poor small-bowel cleansing level.

Conclusion

Evaluation for the disease surveillance of primary small-bowel FL managed with a watch-and-wait policy or chemotherapy using CE images by the developed CNN system was considered useful under the condition of excellent small-bowel cleansing level.

Introduction

The prevalence of functional dyspepsia (FD) and gastroparesis in diabetic patients remains unknown. A high prevalence of gastroparesis has been reported in diabetic patients reaching up to 5%.¹ However, recent consensus specified the symptom pattern for gastroparesis, with nausea and/or vomiting as predominant symptoms, now defined as “gastroparesis-like symptoms” (GPLS).² The global prevalence of GPLS has been estimated to reach only 1.2% in diabetic patients, but type 1 and type 2 diabetes were not assessed separately.²

Aims & Methods

We aimed to assess the prevalence and burden of FD and GPLS in primary care patients with diabetes, comparing patients with type 1 and type 2 diabetes. An online survey was addressed to diabetic patients through general practitioners and diabetic patient associations. The survey included the Rome IV questionnaire and the Patient Assessment of Gastro-Intestinal Disorders-Symptom Severity Index (PAGI-SYM) for upper gastro-intestinal symptoms. Anxiety, depression, somatization, and quality of life were also assessed by specific questionnaires (Generalized Anxiety Disorder GAD-7, Patient Health Questionnaire PHQ-9, PHQ-15, and PAGI-QoL questionnaires respectively).

Results

A total of 216 patients completed the questionnaires, among which 146 had type 1 diabetes, and 68 had type 2 diabetes, (2 patients did not know their type of diabetes). The median age of the population was 56 (50-61) years old, with 134 female patients (61.8%). The prevalence of FD was 13.0% with no difference between the 2 groups. The prevalence of GPLS reached 4.2% and was significantly higher in patients with type 2 diabetes (8.9% vs 2.1%; p=0.03). The burden of upper gastro-intestinal symptoms and their impact on quality of life was higher in type 2 diabetes patients with higher PAGI-SYM and PAGI-QoL scores while anxiety and somatization were not different between type 1 and type 2 diabetes patients (see Table). Overall, patients with GPLS had higher anxiety (9 vs 3; p=0.003), depression (12 vs 3; p=0.001) and somatization scores (16 vs 6; p<0.001) than patients without. Compared to patients with FD without GPLS, GPLS patients had numerically higher but not statistically different scores for symptom severity (51 vs 28; p=0.46), anxiety (9 vs 7; p=0.29), depression (12 vs 7; p=0.07), somatization (16 vs 11.5; p=0.16) and quality of life scores (52 vs 24; p=0.16).

Conclusion

This study confirms that the prevalence of GPLS seems to be higher in diabetic patients compared to available population data, especially in patients with type 2 diabetes. The impact of the symptoms was similar to the impact of FD in this population. Further studies are required to assess the prevalence of delayed gastric emptying in diabetic type 1 and 2 patients with GPLS.

References

1. Choung RS, Locke GR, Schleck CD, et al. Risk of Gastroparesis in Subjects with Type 1 and 2 Diabetes in the General Population. Am J Gastroenterol 2012;107:82-88.
2. Huang I-H, Schol J, Khatun R, et al. Worldwide prevalence and burden of gastroparesis-like symptoms as defined by the United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis. United European Gastroenterol J 2022;10:888-897.

Clinical Case Summary

Background: Colorectal anastomotic strictures affect up to 30% of colorectal cancer surgery patients, but complete obstruction is rare. Endoscopic approaches, relying on successful guidewire passage through the stenosis followed by dilation or stent placement, may avoid surgical revision. In cases of insurmountable strictures in patients with colostomy, guidewire passage under endoscopic ultrasound (EUS) or direct endoscopic guidance, using transillumination, can be considered.
Methods: A 78-year-old underwent urgent high anterior resection with a transverse loop colostomy due to an occlusive rectal tumor. By postoperative day 8, he had anastomotic leakage, requiring reintervention. Ten months post-surgery, colonoscopy showed a complete unnegotiable anastomotic stricture. A pediatric colonoscope was inserted through the colostomy, and a therapeutic gastroscope was introduced via the rectum, both advanced to opposing sides of the stricture. Fluoroscopic confirmation of scope positions was followed by transillumination-guided puncture of the colonic side of the stricture with a 6 Fr cystotome. A guidewire was passed through the fistula and retrieved using forceps in a rendezvous manner. Balloon dilation of the fistula up to 4 mm enabled the deployment of a 16x20 mm lumen-apposing metal stent (LAMS). Contrast medium injection confirmed the correct positioning and patency of the LAMS. The patient was discharged home on the same day.
Results: At the 3-month follow-up sigmoidoscopy, the anastomosis was patent, while the stent had migrated and was removed. Colostomy reversal was successfully performed one day later. At the 6-month follow-up, the patient reported regular bowel movements without any residual symptoms.
Conclusion: Freestyle puncture of the excluded rectum using a cystotome followed by LAMS apposition during a dual endoscopic-fluoroscopic procedure seems to be a safe and effective treatment for recanalizing complete colorectal anastomotic strictures.

References

Clinical Case Summary

A 65-year-old man was admitted to our emergency department presenting with intermittent abdominal distension and difficulty in defecation for over a month, and absence of passage of stool and gas for 3 days. Soft tissue masses of sigmoid colon wrapping the left ureter on abdominal CT and a large nodular neoplasm in the sigmoid colon on colonoscopy were observed. Advanced colon cancer was highly suspected. However, we made sixes times biopsy totally and found no evidence of malignancy. Histopathology only showed moderate to severe chronic mucosal inflammation. We finally performed the subtotal colectomy and the histopathology of the excised colon showed us an unexpected finding: Schistosoma japonicum ova.
According to the data published by WHO in 2020, schistosomiasis has been reported in 78 countries worldwide, resulting in an estimated 240 million deaths¹. These highlight the significance of schistosomiasis eradication. Further history taking observed that the patient swam in the Baishui River, a tributary of Yangtze River, an endemic area of schistosomiasis, in recent four years of summer vacation.
During endoscopic examinations, patients may have characteristic scattered yellow nodules, while non-specific mucosal congestion, edema, thickening, ulcers, and polyps may be commonly observed. Therefore, misdiagnosis of intestinal schistosomiasis is common, with the rate of 30.3%^2,3. As we know, we made the first report of intestinal schistosomiasis infiltrating peritoneum and ureter, mimicking advanced colon cancer or Crohn’s disease. This highlights the importance of multi-site and deep biopsies or even surgery for the diagnosis of colonic neoplasm, especially when Schistosoma ova are distributed focally in submucosal area. Moreover, Schistosoma are far from eradication. Physicians should include schistosomiasis as a common differential diagnosis of colonic neoplasm. Detailed history taking of travel and migration is necessary in these patients.

References

(1) Díaz, A. V.; Walker, M.; Webster, J. P. Reaching the World Health Organization Elimination Targets for Schistosomiasis: The Importance of a One Health Perspective. Philos Trans R Soc Lond B Biol Sci 2023, 378 (1887), 20220274. https://doi.org/10.1098/rstb.2022.0274.
(2) Yang, Y.; Wang, X.-Y.; Duan, C.; Wang, Z.-J.; Sheng, H.-Y.; Xu, X.-L.; Wang, W.-J.; Yang, J.-H. Clinicopathological Characteristics and Its Association with Digestive System Tumors of 1111 Patients with Schistosomiasis Japonica. Sci Rep 2023, 13 (1), 15115. https://doi.org/10.1038/s41598-023-42456-9.
(3) Cai, L.; Chen, Y.; Xiao, S.-Y. Clinicopathologic Features of Chronic Intestinal Schistosomiasis and Its Distinction From Crohn Disease. Am J Surg Pathol 2021, 45 (3), 430–438. https://doi.org/10.1097/PAS.0000000000001594.

Introduction

Dietary and lifestyle recommendations are the cornerstones of the treatment of GERD. However, the evidence of the efficacy of those recommendations is lacking. We performed a retrospective analysis of the GISTAR study¹ participants evaluating the symptoms of GERD and dietary and lifestyle parameters developing a tool for predicting GERD symptoms based on the aforementioned criteria.

Aims & Methods

The aim of the study was to analyse the factors pointing to GERD symptoms through the use of data mining and decision tree classifier.
Methods: GERD diagnosis was evaluated using a self-assessment questionnaire ². Dietary, demographic and lifestyle data were collected within the GISTAR study protocol¹. 3340 40-64 year old participants from the GISTAR study were included in the analysis. 1670 of them did not have GERD symptoms. 41 attributes describing demographic, lifestyle, and dietary habits were used for these respondents to induce a decision tree classification model using Orange Data Mining software³.

Results

Fried potatoes including French fries were the most predictive factor of GERD symptoms (65.3% with symptoms; 1516 from 2321), especially for females (82.6%; 1048/1228). This was more pronounced in the group who consumed sweets once per week (87.2%, 950/1090). In males, who consumed fried potatoes, the next most important factor was the consumption of sweets (46.3%, 431/930).
For participants who didn’t consume fried potatoes (14.6%; 147/1008), 1-3 cups of green tea (37.9%; 66/174) and male gender (71.4 % 20/28) were predictors of GERD symptoms.
The accuracy of the decision tree model was: sensitivity (74.8%), precision (75.6%), specificity (75.9%) and AUC (0.841%).

Conclusion

Fried potatoes, female gender and consumption of sweets are the risk factors predicting the diagnosis of GERD. None of the lifestyle factors were displayed as significant.

References

1. Leja M, Park JY, Murillo R, et al. Multicentric randomised study of Helicobacter pylori eradication and pepsinogen testing for prevention of gastric cancer mortality: the GISTAR study. BMJ Open 2017;7:e016999. doi: 10.1136/bmjopen-2017-016999
2. Jones R, Junghard O, Dent J, Vakil N, Halling K, Wernersson B, Lind T. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. Aliment Pharmacol Ther. 2009 Nov 15;30(10):1030-8. doi: 10.1111/j.1365-2036.2009.04142.x. Epub 2009 Sep 8. PMID: 19737151.
3. Demsar J, Curk T, Erjavec A, Gorup C, Hocevar T, Milutinovic M, Mozina M, Polajnar M, Toplak M, Staric A, Stajdohar M, Umek L, Zagar L, Zbontar J, Zitnik M, Zupan B (2013) Orange: Data Mining Toolbox in Python, Journal of Machine Learning Research 14(Aug): 2349−2353.

Introduction

Transient elastography (TE) by Fibroscan® is a widespread method for non-invasive evaluation of liver stiffness measurement (LSM). Point-shear wave elastography (pSWE) is an alternative non-invasive method for this type of assessment. Transient elastography is also able to evaluate hepatic steatosis by the function Controlled Attenuation Parameter (CAP).

Aims & Methods

We aimed to compare the results of TE and pSWE for fibrosis assessment in patients with non-alcoholic steatohepatitis (NASH), stratified by the degree of steatosis.
​Consecutive patients with established diagnosis of NASH attending our Gaastroenterology Unit underwent liver stiffness measurement (LSM) by both TE and pSWE. Liver steatosis was measured by CAP and the severity was graded into S0-S3. At least 10 measurements were performed and results were expressed as median with interquartile range. Statistical analysis was conducted by Pearson’s test for correlation and linear regression. Bland-Altman graphs with bias and ROC curves with estimation of sensitivity, specificity, and area under the curve (AUC) were drawn.

Results

Seventy-seven patients were recruited (17 females, 60 males, aging 54.1 ± 13.9). The overall correlation between TE and pSWE was moderate (r=0,63, p < 0.001). Linear regression showed a “b” coefficient of 0.99 ± 0.033. The Bland-Altman plot found a bias of -0,52 and only six valued exceeded the 95% CI limits. When considering patients with mild steatosis (S1), we found a strong correlation (r=0.81, 95% CI 0.39-0.95, p=0.003). The highest correlation between TE and pSWE was recorded for S2 subjects: r=0.90 (95% CI, 0.64-0.98, p<0.001). The correlation was low in S3 patients (r=0.42, 95% CI, 0.09-0.67, p=0.001). A cut-off of 11.15 kPa of pSWE had sensitivity=87,50 % and specificity=97,10% to detect relevant fibrosis, with an AUC=0.98 compared to TE.

Conclusion

pSWE and TE showed comparable LSM in NASH. A good concordance was observed in patients with mild or moderate liver steatosis, while in S3 patients we observed a weaker agreement between the two techniques.